Endometriosis is a somewhat mysterious but increasingly common condition. While the lining of the uterus (endometrium) normally grows inside the uterine cavity, in endometriosis this tissue grows in other areas of the pelvis, even outside the pelvis entirely. One of the most common areas is behind the uterus which is called the “cul-de-sac”. Endometriosis also frequently involves the ovaries. Endometriosis can also be found in conjunction with scarring of the pelvic structures.
Besides pelvic pain, endometriosis can be associated with infertility and abnormal menstrual cycles. Because symptoms vary a great deal from woman to woman, and mimic other medical conditions, endometriosis is often misdiagnosed. While symptoms can raise the suspicion of the disorder, a firm diagnosis is usually made only after laparoscopy. In this procedure, a lighted scope is inserted into the pelvic cavity through a small incision around the navel, allowing the physician to actually view the condition. In many cases lasers can be used to treat the endometriosis at the same time.
The American Fertility Society has established criteria for classifying endometriosis based on where the tissue is growing, whether it is on or buried beneath an organ’s surface, and whether filmy or dense adhesions are found. Considering these factors, a doctor may classify the disease as minimal, mild, moderate or severe. Tests also may be done to determine if fertility has been affected.
Treatment depends on a woman’s symptoms, pregnancy plans, and age, as well as the extent of the disease. Frequently endometriosis can be treated at the time of diagnosis with laparoscopic lasers. The laser is effective in treating endometriosis while reducing surrounding tissue injury. Hormonal treatment can be used by itself or as an adjunct to surgery. These drugs act on the pituitary gland to make a woman temporarily menopausal, thereby allowing the endometriosis to regress by stopping the hormonal stimulation. When hormone levels are decreased, symptoms often disappear and the disease becomes inactive. Endometriosis may recur after treatment. Recurrence is more common with mild to severe cases. Recurrence is usually over a period of months to years.
Surgery is usually necessary for moderate to severe disease-characterized by patches of tissue larger than two inches in diameter, significant adhesions in the lower abdomen or pelvis, or endometrial tissue that obstructs one or both fallopian tubes or that is causing extreme pain unrelieved by drugs. Sometime electrocautery (using an electrical current to produce heat) or laser is used to remove endometrial tissue. Again, the tissue may regrow after surgery. Only the surgical removal of both ovaries prevents endometriosis from recurring.
In Vitro Fertilization is commonly used to treat endometriosis cases where lesser treatment has not worked. IVF bypasses scar tissue and inflamation that can cause infertility in endometriosis cases.
The cause of endometriosis is not completely known, some factors are extremely important. A family history of endometriosis may suggest genetic factors. Some deformities of the uterus such as obstruction can cause endometriosis. Also, uninterrupted menstruation for long periods of time may also predispose an individual to develop endometriosis. As an example, a thirty-eight year old women who has never had a child is more likely to have endometriosis then a similar age individual who has had several children. One mechanism of developing endometriosis we believe is reverse menstruation were the menstrual fluid drains partially out the fallopian tubes and becomes imbedded in the pelvic organs.
Patients who have longer and heavier menstrual periods are at increased risk of endometriosis. Patients with a strong family history of endometriosis are at an increased risk. Individuals who have prolonged infertility are also commonly found to have endometriosis.
The most common symptoms of endometriosis are pelvic pain and infertility. The pain may be associated with menstruation, which we refer to as dysmenorrhea. The pain may be associated with intercourse, which we refer to as dyspareunia. Pelvic pain may also occur at other points in the menstrual cycle. Among patients with infertility there is a very high prevalence of endometriosis. Some studies have shown that 30-50% of individuals presenting with infertility have endometriosis. It is important to know that infertility may be the sole symptom of the endometriosis. In other words, in many patients endometriosis does not present itself with pain but only with infertility.
Endometriosis is diagnosed through careful history taking and physical examination. On pelvic examination there can be clues to the presence of endometriosis based on the consistency of the tissue. Also, irregularity in the tissue behind the uterus, which we call the cul-de-sac can be a tip. Large collections of endometriosis in the ovaries, which we call endometriomas can also be palpated. Another diagnostic modality is ultrasound. Ultrasound is effective in diagnosing severe endometriosis. Probably the gold standard of diagnosing is laparoscopy. Laparoscopy allows us to visualize the reproductive tract directly. Endometriosis then can be evaluated and frequently treated at the same time.
Frequently we can treat endometriosis at the time of diagnosis during laparoscopy. This is usually done using laser therapy. Laser therapy can destroy the endometriotic implants without damaging surrounding tissue. The benefits of laser therapy are that for patients that wish to conceive it allows them the opportunity to immediately attempt conception. Hormonal therapy is also available in the form of drugs such as Lupron to shut down the ovaries or progesterone to suppress the endometriosis directly. The advantage of medical therapy is the elimination for the need for surgical intervention. However, medical therapy generally suppresses ovulation for 6-9 months. For the patient that wishes to conceive this may be an unacceptably long time to defer attempts at conception.
Because laparoscopy is a relatively new modality which has been utilized only in the last twenty years, it is possible that we are diagnosing more cases. However, there is a suspicion that we are seeing more endometriosis now then we were years ago. Endometriosis is promoted by many months of regular menstruation, which are uninterrupted by childbirth. With the increasing availability of oral contraceptives, and with a generally increasing trend for women to work longer before attempting their first childbirth, it is suspected that perhaps this is allowing for more uninterrupted menstruation, which may be a risk factor for endometriosis. While endometriosis is probably most commonly diagnosed in the mid to late thirties, we are seeing an increasing number of women in their twenties with moderate to severe endometriosis. This poses a significant threat to their future reproduction.